PRIMARY HEALTH CARE.doc

1. PRIMARY HEALTH CARE
INTRODUCTION
In India a lot of health problems and health care services are there. It
is implemented through various activities, which may range from higher
level to the lower level. For building a house we need a strong foundation,
without which we cannot construct a roof. In the same way in our health care
service also there is a basic level of health care without which we cannot go
to the higher level; which is the back bone of our health care system-that is
primary health care.
TERMINOLOGIES
 Endemic disease: It refers to the constant presence of a disease or
infectious agent in a given geographical area or population group,
without importation from outside
 Referral service: Referring a patient for second opinion or treatment to
a specialist hospital.
 Primordial prevention: It includes measures for prevention of
emergence of risk factors.
 Primary prevention: Action taken prior to the onset of disease, which
removes the possibility that a disease will ever occur.
 Secondary prevention: Action which halts the progress of a disease at
its incipient stage and prevents complications.
 Tertiary prevention: It is the action taken to reduce the disability.

2. DEFINITION:
The Alma-Ata conference in 1978 defined Primary health care as
“primary health care is an essential health care made universally accessible
to individuals and acceptable to them through their full participation and at
a cost the community and country can afford”
PRIMARY HEALTH CARE MOVEMENT:
With the increasing recognition of the future of existing health
services to provide health care, alternative ideas and methods have been
considered. Discussing these issues at the joint WHO-UNICEF international
conference in 1978 at Alma-Ata, the governments of 134 countries and
many voluntary health agencies called for a revolutionary approach to health
care. Declaring that “the existing gross inequality in the health status of
people particularly between developed and developing countries as well as
with in the countries is politically, socially and economically unacceptable”,
the Alma-Ata conference called for acceptance of the WHO goal of “health
for all by 2000AD” and proclaimed primary health care as a way to
achieving health for all. Primary health care got off to a good start in many
countries with the theme.
In India
1946---Bhore committee recommended to have primary health care for rural
community.
1977---Rural health scheme launched.(based on the recommendation of
Shrivasthav committee in1975
Primary health care movement started based on Alma-Ata declaration.

3. ELEMENTS
The Alma-Ata declaration has outlined 8 essential components
1. Education concerning prevailing health problems and the methods of
preventing and controlling them.
2. Promotion of food supply and proper nutrition.
3. An adequate supply of safe water and basic sanitation.
4. Maternal and child health care including family planning
5. Immunization against major infectious diseases
6. Prevention and control of locally endemic diseases.
7. Appropriate treatment of common diseases and injuries.
8. Provision of essential drugs
E----Ensure safe water supply
L----Locally endemic disease control
E----Education/ Expanded programme on immunization
M----Maternal and child health
E----Environmental sanitation
N----Nutritional services
T----Treatment of common diseases and injuries
S----Supply of drugs
All these are included in primary health care in India.
IN INDIA
 EDUCATION
Health education programmes for different groups of people to
educate them about the prevention and control of various health
problems in the community and the need for health promotion. It is
incorporated in all health programmes.

4.  NUTRITION
Nutritional status is improved by nutrition education, making
kitchen garden and community gardens, grow vegetables, fruits,
pulses and legumes in their farms. Also there is nutritional
programmes in India.
 SAFE WATER SUPPLY AND BASIC SANITATION
It is targeted through comprehensive National water supply and
sanitation programme launched by the union government in 1954
which reviewed and revised in 1981 and 1991. It aims both urban and
rural population.
In basic sanitation program emphasis given sewerage system in
cities, low cost sanitation facilities in towns, low cost sanitation
latrines in rural area, soakage pits for disposal of waste water etc.
 REPRODUCTIVE AND CHILD HEALTH
It focuses mainly on antenatal registration, conduct of delivery
by trained personal, postnatal and newborn care, immunization, small
family norms etc.
 COMMUNICABLE DISEASE CONTROL
It continues to be the major health problem in India. Health
workers are trained in prevention and control of these diseases and the
related programmes.

5.  TREATMENT OF MINOR AILMENTS AND INJURIES
It needs to be treated at the village level. Sub centers and primary
health centers are equipped to deal with common diseases and injuries.
Referral. service facility is also there.
 ESSENTIAL DRUGS
PRINCIPLES OF PRIMARY HEALTH CARE
Park’s text book of preventive and social medicine:
The principles are
 Equitable distribution
The health services must be shared equally by all people
irrespective of their ability to pay and all(rich or poor, urban or rural) must
have access to health services.
 Community participation
Community should be involved in planning, implementing and
maintenance of health services by utilizing man, money and materials. One
successful approach is the role of village health guides and trained dais.
 Intersectoral co-ordination
Planning with sectors like agriculture, animal husbandry,
food, education, industry, housing, public works, communication and others
are needed.

6.  Appropriate technology
It is defined as technology that is scientifically sound,
adaptable to the local needs and acceptable to those who apply it and those
for whom it is used and that can be maintained by the people themselves in
keeping with the principle of self reliance with the resources the community
and country can afford.
“Essentials in community health nursing practice “by Kamalam.S
It explains one more principle than the above mentioned. That is
 Focus on prevention:
All levels of prevention are included here.
“Community health nursing Principles and practice” by K.K.Gulani
 Equitable distribution
 Community participation
 Multisectoral approach
 Appropriate technology
 Human resources
 Service by community health workers and traditional health
practitioners
 Referral systems
 Logistics of supply
 The physical facilities
 Control and evaluation
PRIMARY HEALTH CARE INFRASTRUCTURE
Primary health care is the first level of contact between public an
health workers. Services for prevention, diagnosis, treatment, rehabilitation
and health promotion are provided through primary health services.

7. Infrastructure of rural primary health care
Attempt was made to organize the health service according to the
size of population, density of population and geographical region of the
country. For this purpose finance was made available to state government
under minimum need program.
Population Coverage of Health Centers based on 1991census.
Health centers
Coverage of population
living in plain areas
Coverage of population
living in hilly/tribal
areas.
Sub centers 5000 3000
PHC 30000 20000
CHC 1,20000 80000
Structural Shortcomings:
- Level of health care is much below the expected level
- Appropriate infrastructure is not available
- Lack of trained professionals
- Improper arrangement of primary referral units
- Inappropriate selection of place for health center
Infrastructure of urban Primary Health Care
Unlike rural health service there is no set standard for the
infrastructure of urban health service. Due to improper planning of

8. organization there is non availability of primary health services or
they are not being used properly.
The target in urban health service:
- Appropriate outdoor services.
- Minimum 10 beds should be available at urban health centers.
- Pharmacy, radiology and diagnostic facilities should be
increased.
- Referral services and vehicles for patients.
- Facilities for delivery, infant and child health care services
should be made available.
- Specialist medical care.
- Counseling about reproductive health and methods of
contraception.
- Dental services.
- Emergency and trauma care.
- Prevention and protection against communicable and non
communicable diseases.
Xth FIVE YEAR PLAN (2002-2007)AND PRIMARY HEALTH CARE
SERVICES.
Priorities: Correcting the unavailability of physical infrastructure
man power and consumables in sub center, primary health center and
community health center.
PRIMARY HEALTH CARE IN INDIA
Keeping in view of the WHO goal of “health for all by 2000AD”, the
government of India evolved a national health policy based on primary

9. health care approach. It was approved by parliament in 1983. The services to
implement the national health policy objective are:
1. Village level
2. Sub center level
3. Primary health center level
4. Community health center level
1. Village level:
Health services should reach to the farthest reaches of rural areas
the following schemes are in operation.
a. Village health guides scheme
b. Training of local dais
c. ICDS scheme.
a. Village Health Guide:
A Village health guide is a person with an aptitude for social
Services and is not a full time government functionary. The scheme was
introduced on 2nd October 1977 with the idea of securing the people’s
participation in the care of their own health.
Selection:
 Should be permanent residents of the local community.
 Should be able to read and write.
 They should be acceptable to all sections of the community.

10.  Should be able to spare at least 2-3 hours every day for community
health work.
After selection they should undergo a short training in primary health care(3
months)
Duties:
-Treatment of simple ailments and activities in first-aid
-MCH including family planning
-Health education
-Sanitation
3.23 lakh village health guides are there in the country.
b. Local dais:
Objective of V111 the five year plan is to train all the untrained
Dais. A one month training programme is under taken by all local dais to
improve their knowledge in the elementary concepts of MCH and
sterilization, obstetric skills. After training a delivery kit will be provided to
her.
c. Anganwadi worker:
Under ICDS scheme, there is an anganwadi worker for a population
of 1000.There are about 100 such workers in each ICDS project.5320 ICDS
blocks are functioning in the country. She is selected from the community
she is expected to serve. A four month training will be given to her on
health, nutrition and child development.
2. Sub-center level:

11. It is the peripheral outpost of the existing health delivery system in
rural area. One sub center for every 5000 population in general and one for
every 3000 population in hilly, tribal and backward areas. One male and one
female multipurpose health worker will be there. As on 31-03-2003, 138368
sub centers are there.
Functions:
-MCH care
-Family planning
-Immunization
It is proposed to extend the facilities at all sub centers for IUD insertion and
simple lab investigations. They will be supervised by male and female health
assistants. The ratio of health assistant to health worker is 1:6.
Staffing pattern:
Health worker female/ANM 1
Health worker male 1
Voluntary worker 1
Total 3
3. Primary Health Center level :(PHC)
Bhore committee in 1946 gave the concept of PHC for providing
comprehensive health service. Each PHC is distributed among 10000-20000
population with 6 medical officers,6 public health nurses and other
supporting staff. But it is not fully implemented. In 1983 national health
plan proposed to reorganize PHC on the basis of one PHC for every 30000
rural population in the plains, with one PHC for every 20000 population in
hilly, tribal and backward areas. Currently there is 22936 PHC’s have been
established, but the actual requirement is 23000 PHC’s.(31-03-2003)

12. Functions:
According to Alma-Ata
1. Medical care
2. MCH including family planning
3. Safe water supply and basic sanitation
4. Prevention and control of locally endemic diseases
5. Collection and reporting of vital statistics
6. Education about health
7. National health programmes
8. Referral services
9. Training of health guides,health workers,health dais and health assistants.
10. Basic laboratory services.
Staffing pattern:
Medical officer 1
Pharmacist 1
Nurse midwife 1
Health worker female 1
Block extension educator- 1
Health assistant(male) 1
Health asst.(female)/LHV 1
UDC 1
LDC 1
Lab technician 1
Driver 1
Class1V 4

13. Total 15
4. Community health center level:(CHC)
As on 31-03-2003,3076 CHC’s were established by upgrading
PHC’s.Each CHC covers a population of 80000 to 1.2lakh with 30 beds and
specialists in surgery, medicine, obstetrics and gynecology and paediatrics
with X ray and laboratory facilities. For strengthening CHC a new non
medical post called community health officer has been created.
Staffing pattern:
Medical officer 4
Nurse midwives 7
Dresser 1
Pharmacist/compounder 1
Lab technician 1
Radiographer 1
Ward boys 2
Dhobi 1
Sweepers 3
Mali 1
Chowkidar 1
Aya 1
Peon 1

14. Total 25
ROLE OF NURSE IN PRIMARY HEALTH CARE:
 Collaborator:
She works collaborately with the members of the health team in
assessing the health status, planning of intervention implementing
and evaluating of health services.
 Adviser:
She advises family and community regarding ways to
handle health problems properly.
Role of Nurse in
Primary health
Care
Promoter of health
Preventor of illness
Advocate
Consultant
Consultant
Adviser
Collaborator
or
Practitioner
Participant
Manager
Potentiator
Team leader
Observer
Care Provider

15.  Consultant:
They shares nursing knowledge and experiences with
authorities in planning and implementing the health programme.
 Advocate:
She encourages and supports the people to take right
decision in maintaining there health and protect patient’s and
individuals rights in relation to health care.
 Preventor of illness:
They practices disease prevention by conducting
immunization clinics, organizing pulse polio immunization mass
campaigns, acting as an epidemiologist during an epidemics,
counseling on nutrition and other disease prevention, and many
more disease control and eradication programmes.
 Promoter of health:
She act as an educator who teaches the importance of
breastfeeding, nutrition, weaning, family welfare practices and
environmental sanitation as a package to the individuals, families
and groups. She as to act according to the felt needs of the
community.
 Care provider:
She as to provide skilled care in all stages of development.
 Team leader:

16. Health team is a group of persons which consists of medical
officer, community health nurse, block extension educator, health
supervisors, community volunteers and trained dais.
 Observer:
She has to make constant observation in the community
about the usual and unusual occurrence of disease.
 Potentiator:
The community health nurse is expected to act as the
motivator, potentiator by virtue of her specialization and
experiences. She should take appropriate actions in solving
the health problems effectively.
 Manager:
The community health nurse is expected to organize and
manage various planned programmes of health and assume
leadership in organizing, implementing and monitoring of
health activities.
 Participant:
As a representative of the health she will participate in
conferences, meetings, workshops, seminars, orientation of
training camp, collector meeting and in implementation of
health programme.
 Practitioner:
She creates awareness in health that would promote their
general well being of the people. She encourages the people to

17. take active participation in the community health programmes.
She also develops rapport with other sectors.
CURRENT ISSUES
- The current PHC structure is extremely rigid, making it unable to
respond effectively to local realities and needs.
- The number of health care providers in the PHC is same
throughout the country despite of the fact that some states have
twice the fertility level of others.
- Political interference in the location of health facilities results in an
irrational distribution of PHCs.
- Lack of resources.
- Lack of accountability.
STRATEGIES:
- Encouraging community involvement which improves governance
and accountability of primary health clinics.
- Capacity building to improve the knowledge and skill of workers.
- Recruiting the qualified personnels.
- Resource management.
- Modification / changing of basic and post basic education
programme.
- Conduct of research.
ABSTRACTS
1. A case study was conducted on ‘An innovative model for
conducting a participatory community health assessment’ in Utila
island.

18. Result:
The wide range of perceived health needs reflected the PHC
issues of access, equity and affordability. All participants strongly express a
concern for the health of their youth. They also contributed the need of an
health education programme for reducing the illiteracy.
2. A study was conducted at department of pediatrics, AIIMS, New
Delhi about Newborn care at peripheral care facilities.
Results:
It shows most of the deliveries are conducted by nurses and
not the doctors. Neonates are kept in the facility for only one day. Hardly
any deliveries take place at PHCs. PHCs seldom admit a sick neonate. The
newborn care rendered by PHC is very less.
3. A research was conducted by Alzheimer’s disease international in
Goa. The qualitative study used to focus the status of older people
and attitudes regarding dementia. The informants were older
people living in the community, community leaders, community
health care workers including primary health care professional.
Result:
There is a need to improve the access of health care for the
elderly. It suggest to improve the primary health care facilities in
the area.
CONCLUSION:

19. In implementing the primary health care service, the nurses
have a major role, who is an efficient person in knowing the health needs
and problems of the people. Even though it has many short comings primary
health care is needed in giving an integrated health care service to the
community.
BIBLIOGRAPHY:
Text books
1. Park K. Park’s text book of preventive and social medicine. 18th
ed.Jabalpur:Banarsidas Bhanot Publishers;2005.p:686-687,695-
697.
2. Kamalam S. Essentials in community health nursing practice.
New Delhi: Jaypee Brothers medical publishers.2005. p:160-
178.
3. Swarnkar S.Community health nursing. Indore :N.R. Brothers
publishers; 2005. p17-20.
4. Gulani K.K. community health nursing, principles and
practices. New Delhi: Kumar Publishing House; 2005. p: 574-
586.
5. Stanhope M & Lancaster J.Community Health Nursing-
promoting health of aggregates, families and individuals. 4th ed;
London :Mosby publishers; 1996 .P: 38-41.
Journals:
1. Running A & Martin K. innovative model for conducting a
participatory community health assessment. Journal of

20. community health nursing.winter 2007; 24(4); Page no:203-
204.
Website:
1. www.google.com
SEMINAR
SUBJECT:ADVANCED CONCEPTS OF
HEALTH AND NURSING
TOPIC:PRIMARY HEALTH CARE
Submitted to
Dr.N.V.Muninarayanappa
Vice principal / P.G. Coordinator
J.S.S College of Nursing
Submitted by

21. Jyothilekshmi.C.R
1 year MSc Nursing
J.S.S College of Nursing
Submitted on
26-06-2008